COVID_19 pneumonia and congestive heart failure have overlap imaging features. Retrospective study of these two disease differences by CT . Authors- Zhaowei Zhu1, MD, Jianjun Tang1, MD, Xiangping Chai2, MD, Zhenfei Fang1, MD, Qiming Liu3, MD, Xinqun Hu1, MD, Danyan Xu1, MD, Jia He1, MD, Liang Tang1, MD, Shi Tai1, MD, Yuzhi Wu3#, MD, Shenghua Zhou1#, MD Correspondence to: Shenghua Zhou, MD, PhD Department of Cardiovascular Medicine, the Second Xiangya Hospital, Central South University, Changsha, Hunan 410011, PR China. https://doi.org/10.1101/2020.03.04.20031047 medRXiv

1. How to differentiate covid-19 pneumonia
from heart failure with computed
tomography at initial medical contact during
epidemic period
https://doi.org/10.1101/2020.03.04.20031047
Presentation by MMO

2. AUTHORS
• Zhaowei Zhu1 , MD, Jianjun Tang1 , MD, Xiangping Chai2 , MD, Zhenfei Fang1 , MD,
Qiming Liu3 , MD, Xinqun Hu1 , MD, Danyan Xu1 , MD, Jia He1 , MD, Liang Tang1 ,
MD, Shi Tai1 , MD, Yuzhi Wu3# , MD, Shenghua Zhou1# , MD
• 1.Department of Cardiovascular Medicine, the Second Xiangya Hospital, Central
South University, Changsha, Hunan, China.
• 2. Department of Emergency, the Second Xiangya Hospital, Central South
University, Changsha, Hunan, China.
• 3. Department of Radiology, the Second Xiangya Hospital, Central South University,
Changsha, Hunan, China

3. METHODS
• Heart failure n = 12
• COVId n = 12
• Retrospective study

4. RESULTS
• GGO
• Consolidation
• Crazy paving
• Lobes affected
• Septal thickening
No difference ofBetween heart failure and
COVID pneumonia
 But less rounded morphology
 more peribronchovascular thickening
 fissural thickening ,
 less peripheral distribution
were found in heart failure.
Importantly in Heart failure group
 Upper pulmonary vein
enlargement
 Subpleural effusion
 Cardiac enlargement
Some overlaps

5. LAB
• White blood cells and neutrophil count was higher in heart failure group
comparing with that in COVID-19.
• Lymphocytes count – decreased in both group
• No differences between – ESR, CRP, procalcitonin ( PCT)

6. • GOO and septal thickening – common in both diseases
 Contact history
 Fever and respiratory
symptoms
 Lab test – WBC count
normal or decreased,
lymphocytes – reduced
 CT imaging
 Suspected if fulfill contact history and any of 2 of latter 3
 Even without contact history , latter 3 can be evidence for
suspected patients

7. HEART FAILURE
• In the absence of fever , chest umcomfortable or chest pain or apnoea sometimes combined with
respiratory symptoms. ( 4 of 12 patients )
Nearly Half of COVID patient
 May not have fever at admission
In Heart Failure
 Lymphocyte count can also be decreased
Heart failure
o Leucocyte and neurtrophil count –
significantly higher than that of
COVID ( induced by heart failure or
acute MI)
Intrestingly , lymphocyte count was also
decreased in heart failure ( increased in
neutrophil ratio may cause relatively decreased
lymphocyte ratio. And also due to increased
cortical hormone level after stress response)

8. Heart failure
• Central and gravity associated
distribution
• Peribronchovascular thickening
and interlobular septal
thickening
• Progress more rapidly at first
COVID
 More lesions with rounded
morphology
 Progress- with different
imaging features at different
stages last for about 2-3 wks
 At first GOO-gradually spread
and consolidate
Interestingly, the CT imaging characteristics of both diseases may be mixed in one patient with
heart failure and COVID-19,
or the features of COVID-19 at initial medical contact will be covered by more progressively
heart failure.
So it should be more careful to contact with a patient with heart failure in epidemic area

9. Heart Failure
 Early loss of definition of subsegmental and segmental
vessels
 Mild enlargement of the peribronchovascular spaces
 Subpleural effusions
 Central distribution
Pathophysiology of central distribution in heart
failure
 increased tissue hydration which allows water to
easily flow centrally,
 the pumping effect of the respiratory cycle
which causes overall fluid flow toward the hilum,
 contractile property of alveolar septa allows
them to expel interstitial edema toward the
hilum.

10. COVID
 Diffuse bilateral interstitial or interstitial-alveolar infiltrates
 Inflammatory pulmonary edema and damage
 Fibromyxoid exudation in lung tissue in autopsy

11.  Although both diseases can have similar GGO and septal thickening, rounded morphology,
peripheral distribution and fibrous lesion were relatively specific in COVID-19.
 While heart failure usually has more peribronchovascular thickening, fissural thickening,
subpleural effusion and cardiac enlargement

12. FIGURE 1, Typical imaging for heart failure and COVID-19 pneumonia.
A, Heart failure with bilateral diffuse disease. The disease presented with a gradient distribution and partial GGO and
consolidation inside, accompanied with subpleural effusion. Peribronchovascular and septal thickening were also
found. B, Heart failure with bilateral diffuse GGO disease. Peribronchovascular thickening, clear interlobular septal
thickening even fissural thickening were found without subpleural effusion. C, COVID-19 with single rounded
subpleural GGO in left lung. D, COVID-19 with rounded GGO in bilateral lungs, partial consolidation was found inside.

13. A, Big patchy GGO in left lung and sporadic GGO in right lung. Peribronchovascular thickening, fissural thickening (arrow) were also
found with subpleural effusion. B, Subpleural GGO with band-shaped morphology (arrow) in the dorsal segment of bilateral lungs.
Interlobular septal thickening and cardiac enlargement were also found. C, Patchy lesion of Crazy Paving Pattern in right upper lung
with partial consolidation inside. Small pulmonary vein enlargement (arrow) was also found, accompanied with subpleural effusion in
the right lung. D, Big patchy GGO in left lung. Interlobular septal thickening was also found inside. E, Multiple disease mixed with GGO
and consolidation in bilateral lungs. Fibrous lesion (arrow) was found in the left lung. F, Patchy lesion of Crazy Paving Pattern in left
upper lung with partial consolidation inside.

14. FIGURE 3, CT imaging of a patient with both heart failure and COVID-19.
A, Diffuse disease mixed with GGO and consolidation in bilateral upper lungs, accompanied with interlobular septal
thickening and subpleural effusion. B, Big patchy GGO with irregular morphology in bilateral lungs. Peribronchovascular
thickening and subpleural effusion were also found.

15. THANK YOU